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She had arrived at the rural hospital earlier on the back of a motorcycle, about the only public transport available in this muddy little town in the distant back-country bush of one of Africa's poorest nations.

Now, in a dark and hot labor ward with rain blowing in the open windows and puddling on the floor, Marah grimaced as James Konteh slapped on rubber gloves and examined her.

Konteh, an ophthalmologist by training, is one of only two doctors who serve 300,000 people in this remote district, so he has become a de-facto obstetrician.

He placed a plastic Pinard stethoscope -- a cheaper, funnel-shaped alternative to a standard stethoscope--to Marah's massive belly and listened.

"The fetal heart rate is very rapid," he said. "The labor is obstructed. The baby is in distress so we must operate right away."

Konteh pulled out his cellphone and began dialing his four surgical nurses. It was 6:30 p.m., and they had all gone home when their 10-hour shifts ended a half-hour earlier.

Marah had waited too long to come to the hospital, and now the baby, her first, was in trouble. The surgery was urgent, but it would take time to get the operating room team back.

"What can I do?" Konteh said. "There's nobody here."

The nurses hooked up an IV to increase Marah's fluids, hoisted her onto a gurney and rolled her into an empty waiting room. She lay there naked, covered loosely by a small cloth, and waited for her caesarian section.

"I haven't been able to sleep for three days," she said. "The pain is too much."

It was a Monday evening, and her husband, Mohamed Barrie, said she had gone into labor on Saturday. Both of them were worried about the expense of going to the hospital, he said, and were sure she could deliver easily enough without assistance from hospital doctors. So they had gone to a neighborhood clinic where a nurse examined her and sent her home.